Buspirone for stereotypic movements in elderly with cognitive impairment

Repetitive and stereotypic behavioral disturbances in patients with dementia are common; however, little is known regarding successful treatments. The authors describe six cases of elderly cognitively impaired patients exhibiting repetitive and stereotypic behaviors who were treated successfully with buspirone. The cases demonstrate that buspirone may be an effective and safe treatment for patients with dementia who demonstrate repetitive and stereotypic behavior disorders.

Suicide and Documentation: Don’t Let the Pen Kill Your Career

1. Nurses' notes must reflect the assessment performed regarding their patients' risk factors, red flags, and protective supports, especially for suicidal patients. 2. Nursing interventions range from the least-restrictive methods to full restraints, if necessary to prevent patients from harming themselves. 3. Medications, such as antidepressant, antipsychotic, and antimanic agents, as well as benzodiazepines, have been shown to help psychiatric patients cope with depression, psychosis, and mood stability.

Suicidal behavior in schizophrenia

There is a high prevalence of suicidal behavior in individuals suffering from schizophrenia and recent investigations substantially elucidate this problem and provide useful insights about clinical risk factors, neurobiologic underpinnings and the impact of various treatments on reducing such behavior. The risk of suicide is greatest early in the course of schizophrenic illness but continues throughout life; risk factors for suicidal behavior include psychosis, depression and substance abuse. Effectively treating positive symptoms and depression, reducing substance abuse, avoiding akathisia, addressing demoralization and instilling hope are important elements in this treatment approach. The newer generation of atypical antipsychotics (particularly clozapine) and new psychologic approaches (particularly cognitive behavioral therapy) appear to be useful in reducing suicidality in schizophrenia. The significant advances in defining the neurobiologic basis of suicidality may enable the development of more effective treatments. The renewed emphasis on resilience and recovery as desired outcomes in schizophrenia and the accompanying sense of hope encourage optimism about effectively reducing suicidality in schizophrenia. Over the past 10 years, much has been learnt and hopefully this momentum will be translated into increasingly better outcomes.

Low-dose venlafaxine in three adolescents and young adults with autistic disorder improves self-injurious behavior and attention deficit/hyperactivity disorders (ADHD)-like symptoms

In our clinical practice, we have had good experiences with venlafaxine in the treatment of self-injurious behavior (SIB) and attention deficit/hyperactivity disorders (ADHD)-like symptoms in patients with pervasive developmental disorders (PDD), and we report here three cases of possible therapeutic response: (A) a 17-year-old boy with autism and severe behavioral symptoms, including aggression toward self or property, SIB and hyperactivity, who appeared to respond to low-dose venlafaxine (18.75 mg/day); (B) a 23-year-old woman with autism hyperactivity who appeared to respond to low-dose venlafaxine (18.75 mg/day); (C) a 17-year-old girl with autism hyperactivity who appeared to respond to low-dose venlafaxine (18.75 mg/day). Follow-ups occurred respectively 18, 36 and 6 months after treatment initiation, making it possible to observe the stability of the clinical improvement in these cases.

Opioids and Down's syndrome

Opioids are used in clinical practice for sedation, anesthesia, and analgesia. Their effects depend on their pharmacokinetic and pharmacodynamic characteristics. The liver is the major site for the biotransformation of most opioids. The major metabolic pathway is oxidation. Metabolism influences distribution, clearance, onset, and offset of opioid drugs. Action also depends on the coupling of opioids with the class of receptors involved and on localization of specific receptors. Three major types of opioid receptors, designated as mu, delta, and kappa, present in the central nervous system, are coupled to G proteins and inhibit adenylyl cyclase. Down's syndrome is a congenital condition characterized by mental retardation and particular physical features. Neurotransmission alterations are important. Alteration in the concentration of opioids in the cortex of these patients has been demonstrated. Neurobiological abnormalities and, in some, abnormalities in the neurotransmission systems, anxiety, and, in particular, nociception all suggest that structural and functional alterations of opioid receptors may be present. A clear knowledge of these multiple abnormalities is essential for skillful management of the perioperative period and for a good outcome for patients with Down's syndrome.

Self injurious behavior in autism: clinical aspects and treatment with risperidone

Self injurious behavior (SIB) is frequent in autistic spectrum disorders. The aim of this study was to investigate the phenomenology of SIB in a group of children with autistic disorder, and to test whether treatment with risperidone might reduce it. A group of eleven children diagnosed with autistic disorder according to the DSM-IV criteria (mean age 8.7+/-2.2 ys) and with severe SIB were recruited for an open study of six months of treatment with risperidone. The Yale-Paris Self-Injurious Behavior Scale was used to delineate the clinical characteristics and as an outcome measure. Head-hitting and hand biting were the most frequent forms of self aggression observed. Nine children presented a mild improvement in SIB and 2 did not show any variation. A decrease in Yale-Paris Self Injurious Behavior Scale score (from M 15.1+/-1.4 to 13.3+/-1.4) was noted mainly due to the reduction of frequency. Side effects of risperidone were not severe.

The efficacy of diazepam treatment for the management of acute wounding episodes in captive rhesus macaques

The spontaneous development of self-injurious behavior (SIB) in singly housed monkeys poses a challenge for their management and well-being in captivity. Relatively little information is available on effective treatments for SIB. This study examined the effects of diazepam (Valium) on self-wounding and other abnormal behaviors in eight individually housed male rhesus monkeys (Macaca mulatta). Each monkey's response to an anxiolytic dose of diazepam (1 mg/kg or greater orally) was compared with the animal's behavior during drug-free periods. When examined across all animals, treatment with diazepam did not significantly alter wounding frequency or rates of self-directed biting without wounding. However, closer examination of the data revealed that four of the animals showed significant decreases in self-biting and wounding frequency (positive responders, PR group), whereas the remaining monkeys showed a trend towards increased wounding frequency (negative responders, NR group). Subsequent examination of colony and veterinary records demonstrated that compared with NR monkeys, PR monkeys had spent significantly more years in individual cage housing and had experienced a greater number of minor veterinary procedures. PR animals also were significantly less likely to have a documented history of self-biting behavior. Our findings suggest that SIB is not a homogeneous disorder in rhesus monkeys; rather, distinct subtypes exist that require different treatment approaches.

Risperidone treatment of autistic disorder: longer-term benefits and blinded discontinuation after 6 months

OBJECTIVE

Risperidone is effective for short-term treatment of aggression, temper outbursts, and self-injurious behavior in children with autism. Because these behaviors may be chronic, there is a need to establish the efficacy and safety of longer-term treatment with this agent.

METHOD

The authors conducted a multisite, two-part study of risperidone in children ages 5 to 17 years with autism accompanied by severe tantrums, aggression, and/or self-injurious behavior who showed a positive response in an earlier 8-week trial. Part I consisted of 4-month open-label treatment with risperidone, starting at the established optimal dose; part II was an 8-week randomized, double-blind, placebo-substitution study of risperidone withdrawal. Primary outcome measures were the Aberrant Behavior Checklist irritability subscale and the Clinical Global Impression improvement scale.

RESULTS

Part I included 63 children. The mean risperidone dose was 1.96 mg/day at entry and remained stable over 16 weeks of open treatment. The change on the Aberrant Behavior Checklist irritability subscale was small and clinically insignificant. Reasons for discontinuation of part I included loss of efficacy (N=5) and adverse effects (N=1). The subjects gained an average of 5.1 kg. Part II included 32 patients. The relapse rates were 62.5% for gradual placebo substitution and 12.5% for continued risperidone; this difference was statistically significant.

CONCLUSIONS

Risperidone showed persistent efficacy and good tolerability for intermediate-length treatment of children with autism characterized by tantrums, aggression, and/or self-injurious behavior. Discontinuation after 6 months was associated with a rapid return of disruptive and aggressive behavior in most subjects.

Psychosurgery for self-injurious behavior in Tourette's disorder

One of the most serious and difficult-to-treat conditions in child and adolescent psychiatry is self-injurious behavior (SIB). SIB can be associated with a number of psychiatric disorders, including mental retardation, schizophrenia, borderline personality disorder, pervasive developmental disorders, stereotypic movement disorder, and Tourette's Disorder. A variety of neurosurgical procedures have been used to treat both intractable SIB and severe Tourette's Disorder. Understandably, there are few reports concerning psychosurgery in children and adolescents for any condition or disorder. This report describes the use of cingulotomy and subsequent limbic leucotomy in an adolescent boy with Tourette's Disorder for SIB. His repetitive and medically serious SIB and failure of all other treatments prompted this intervention after careful, comprehensive review and discussion. Following the second surgery, the severity and frequency of his SIB were reduced.

Escitalopram and suicidality in adult depression and anxiety

The escitalopram clinical trial database, consisting of all placebo-controlled and relapse prevention trials within major depressive disorder (MDD) and anxiety disorders, was analysed for specific adverse events indicative of suicidal behaviour (fatal suicide, non-fatal self-harm or suicidal thoughts) in relation to treatment. The number of events was low, with no fatal suicides in the first 2 weeks of treatment. There was one fatal suicide during the full treatment period on placebo (incidence 0.1%; rate 0.003), and none on escitalopram. None of these figures were significantly different between escitalopram (n=2277) and placebo (n=1814) patients. There was no indication that escitalopram provokes suicidal behaviour compared to placebo in either MDD or anxiety disorders. Based on efficacy ratings (Montgomery-Asberg Depression Rating Scale, item 10), escitalopram was more efficacious versus placebo in lowering suicidal thoughts from weeks 1 through 8 in the treatment of patients with MDD.

Serotonergic antidepressant effects on aggressive, self-injurious and destructive/disruptive behaviours in intellectually disabled adults: a retrospective, open-label, naturalistic trial

There is a growing body of evidence that serotonergic antidepressants are useful in the treatment of maladaptive behaviours in the intellectually disabled. However, not all studies have shown positive results due to lack of efficacy, tolerance development, and troublesome side-effects. The current study consisted of a review of the treatment response to a variety of serotonergic antidepressants, consisting of selective serotonin reuptake inhibitors (SSRIs ) (n = 36) and clomipramine (n = 2) in 38 institutionalized intellectually disabled adults (20 males, 18 females; mean age 45.6 yr, age range 18-74 yr). Those studied were treated for aggression, self-injurious behaviours, destructive/disruptive behaviours, depression/dysphoria, or a combination of these or other challenging behaviours. Most were receiving concurrent psychotropic and/or anticonvulsant medications. Effectiveness was determined by a retrospective review of the summaries of multidisciplinary Neuropsychiatric Behavioural Reviews (NBRs) in which global and specific maladaptive behaviours were rated on a 1- to 7-point scale, and by psychologists' ratings of target behaviours. Overall, statistically significant decreases in the ratings of global maladaptive behaviour and aggression, self-injurious behaviour, destruction/disruption and depression/dysphoria and in psychologists' ratings occurred in the subject group after the initiation of antidepressants. The results suggest that serotonergic antidepressants are useful in the treatment of challenging/maladaptive behaviours in the intellectually disabled.

Minimally effective doses of conventional antipsychotic medications used to treat aggression, self-injurious and destructive behaviors in mentally retarded adults

Retrospective review of records from 1990 to 1997 revealed unsuccessful attempts to withdraw antipsychotic medications from a total of 34 intellectually disabled individuals. The lowest dose of antipsychotic medication necessary to maintain symptom suppression and the dose at which relapse occurred were noted. Target behaviors observed indicating relapse included increased self-injurious behavior, aggression, and destructive/disruptive behaviors. Nineteen subjects received a low potency antipsychotic agent (ie, thioridazine or chlorpromazine) and 15 received a high potency antipsychotic agent (ie, haloperidol, loxapine, thiothixene). The mean lowest effective dose of chlorpromazine/thioridazine was 149.3 mg/d and relapse occurred at a mean dose of 93.6 mg/d. The mean lowest effective dose of haloperidol or related high potency drugs (expressed as haloperidol equivalents) was 5.9 mg/d, and relapse occurred at a mean dose of 3.8 mg/d.

Research knowledge among parents of children participating in a randomized clinical trial

OBJECTIVE

Parental permission is required for child research, but parents' understanding of research aims and procedures has not been well documented. Parental research knowledge was assessed during a clinical trial in autism.

METHOD

Parents of 101 children (age 5-17 years) with autism participating in a placebo-controlled trial of risperidone were given a questionnaire at the end of the study.

RESULTS

Of the 95 parents completing the questionnaire, 99% knew of possible placebo assignment and that testing the medication efficacy was the main purpose of the investigators; 96% to 98% knew that research involved both risks and potential benefits, identified the study medication, and knew of their right to withdraw at any time; 90% to 95% knew of the medication's main side effects; 87% reported having been informed of possible alternatives to research participation; and 72% were aware that treatment was randomly assigned (whereas 27% reported that treatment was chosen based on individual needs to ensure best care). Parents with a college degree were more likely to recognize the random nature of treatment assignment.

CONCLUSIONS

Overall, parents were highly knowledgeable of the main research components. About one fourth, however, seemed unaware that treatment was randomly determined and not personalized, suggesting that therapeutic misconception may affect some otherwise well-informed parents.

A retrospective analysis of quetiapine in the treatment of pervasive developmental disorders

BACKGROUND

The purpose of this study was to examine the effectiveness and tolerability of quetiapine for aggression, hyperactivity, and self-injury in pervasive developmental disorders (PDDs).

METHOD

The medical records of all patients with PDDs diagnosed according to DSM-IV criteria and treated with quetiapine were retrospectively reviewed. Patients who received quetiapine for at least 4 weeks and who were not concurrently treated with another antipsychotic or mood stabilizer were included. Improvement was measured with the Clinical Global Impressions-Improvement scale (CGI-I), with response determined by ratings of "much improved" or "very much improved." Data were collected from May 15, 2003 through November 30, 2003.

RESULTS

Of 857 records reviewed, 20 patients (16 male, 4 female) (mean +/- SD age = 12.1 +/- 6.7 years; range, 5-28 years) received a quetiapine trial (mean +/- SD dosage = 248.7 +/- 198.4 mg/day; range, 25-600 mg/day) over a mean duration of 59.8 +/- 55.1 weeks (range, 4-180 weeks). Eight (40%) of 20 patients were judged "responders" to quetiapine; the mean CGI-I score for the entire group was 3.0 +/- 1.1 (minimally improved). A statistically significant improvement (p = .002) was found between a mean pretrial CGI-Severity of Illness scale (CGI-S) score of 5.1 +/- 0.6 (markedly ill) and a posttrial CGI-S score of 4.2 +/- 1.1 (moderately ill). Adverse effects occurred in 50% (N = 10) of patients and led to drug discontinuation in 15% (N = 3) of patients.

CONCLUSION

Quetiapine was modestly effective for maladaptive behavior in patients with a PDD. Controlled studies are needed to further assess these preliminary findings.

Clonidine in acute aversive inner tension and self-injurious behavior in female patients with borderline personality disorder

BACKGROUND

States of strong aversive inner tension and dissociative symptoms are clinical hallmarks of borderline personality disorder and major reasons for self-injurious behavior, a severe clinical condition for which there are no established pharmacologic treatment options.

METHOD

The acute effect of 75 and 150 microg of clonidine administered orally in acute states of strong aversive inner tension and urge to commit self-injurious behavior was examined in 14 female patients meeting DSM-IV criteria for borderline personality disorder. Before and 30, 60, and 120 minutes after administration of clonidine, aversive inner tension and dissociative symptoms were assessed using a self-rating instrument for aversive inner tension and dissociation (Dissociation-Tension-Scale acute), and the urge to commit self-injurious behavior and suicidal ideations were assessed using self-rating Likert scales. Blood pressure and heart rate were monitored during the trial.

RESULTS

Aversive inner tension and urge to commit self-injurious behavior before administration of clonidine were strong. After administration of clonidine in both doses, aversive inner tension, dissociative symptoms, urge to commit self-injurious behavior, and suicidal ideations significantly decreased. The strongest effects were seen between 30 and 60 minutes after drug intake and correspond to the pharmacokinetics of clonidine with maximum plasma concentrations after 1 hour. Blood pressure and aversive inner tension and dissociative symptoms were positively correlated before and after administration of clonidine.

CONCLUSION

Orally given clonidine may be effective for treatment of acute states of aversive inner tension, dissociative symptoms, and urge to commit self-injurious behavior in female patients with borderline personality disorder. Further placebo-controlled studies with larger populations are needed to confirm this finding.

Management of hyperactivity and other acting-out problems in patients with autism spectrum disorder

Hyperactivity/impulsivity, aggression, self injury, and irritability are disruptive behaviors that frequently accompany autism spectrum disorders (ASD). The psychostimulants and atypical antipsychotics have been used with some success to manage hyperactivity, but neither drug group is fully satisfactory and clinical response to the stimulants varies. For other disruptive symptoms (irritability, aggression, self injury), both older antipsychotics and newer atypical antipsychotics have been shown to have helpful effects. Because of potential side effects, atypical antipsychotics should ordinarily be preferred over older agents. A small group of studies suggests that selective serotonin reuptake inhibitors may be helpful in managing symptoms related to aggression, self injury, and the like. A small and largely imperfect literature suggests that beta blockers, mood stabilizers, and alpha-2 agonists may also have some role for treating such symptoms. More research is needed on the management of all of these target symptoms, both for new agents (e.g., atomoxetine) and for established psychoactive medicines.

Neurologic treatment strategies in autism: an overview of medical intervention strategies

Child neurologists are likely to be caring for an increasing number of patients with autistic spectrum disorder (ASD). ASD may occur in as many as 1/100 to 1/200 births. It appears to be a multifactorial disease, with many phenotypes or subgroups. No simple treatment is currently approved for curing or managing core symptoms of autism. We rationally propose a symptom-based review of what treatments may offer relief to specific subtypes of clinical behaviors seen in autism. There is a lack of clinically based evidence on which to universally recommend a rational clinical algorithm for treatment; we suggest that rational pharmacotherapy may offer symptomatic relief to core areas of dysfunction in the autistic population. Future research into rational medical treatment options is desperately needed.

[Two cases of adult Down syndrome treated with selective serotonin re-uptake inhibitor for behavior disorders]

Adult patients with Down syndrome show psychological symptoms and early senility. Improving their environment and dealing with their complaints and stress should first address their behavioral problems, such as self-injury, depression, aggression and outbursts. Pharmacological treatment may also be tried for behavioral disorders. Individuals with Down syndrome demonstrate neurotransmitter changes such as the loss of acetylcholine, norepinephrine, and serotonin (5-HT) with increasing age. Selective serotonin re-uptake inhibitor (SSRI) is effective for depression and panic disorders. We report here the effect of SSRI in two adult male patients with Down syndrome, 35 and 47 years of age. Self-injury in one case and aggression and outbursts in another improved after 1 week of fluvoxamine treatment, suggesting the effects of SSRI for behavioral disorders of adult Down syndrome.